Therapeutic Exercise for the Ankle and Foot Flashcards
Pronation is the combination of what motions
- dorsiflexion
- eversion
- abduction
Supination is the combination of what motions
- plantar flexion
- inversion
- adduction
What muscles do planatrflexion
Primary: gastroc and soleus
Secondary: tibialis posterior, flexor halluces longus, and flexor digitorum longus
What muscles dorsiflex
- tibialis anterior
- extensor halluces longus
- extensor dititorum longus
- fibulas tertius
What muscles do eversion
- fibulas longus
- fibulas brevis
- fibulas tertius
- extensor digitorum
What muscles do inversion
- tibialis anterior
- tibialis posterior
- extensor halluces longus
- flexor digitorum longus
- flexor halluces longus
Line of gravity through the body in quiet standing
- anterior to ankle
- anterior to knee
- posterior to hip
Loading response progressing to mid stance
- foot pronation and lower leg IR
- loose packed position
- conforms to surface
Mid stance progressing to terminal stance
- foot supination and lower leg ER
- closed pack position
- creation of rigid level via windlass effect
When are dorsiflexors active during gait
- initial contact and loading response
- control foot lowering to the ground
When are plantar flexors active during gait
- eccentrically and concentrically during mid stance into terminal stance
When are evertors active during gait
- provide mediolateral stability & prevents involuntary ankle inversion at foot strike
When are investors active during gait
- Tibialis ant./pos. function to control pronation during loading response
When are intrinsics active during gait
- support transverse & longitudinal arches
Intrinsic factors of leg, heel, and foot pain
- pes caves foot type
- high BMI
- decreased ankle DF
- weak intrinsic musculature
- faulty LE alignment
- female
Extrinsic factors of leg, heel, and foot pain
- running
- increase in exercise routine volume
- work demands
- improper footwear
Tendinosis, tendonitis, and tenosynovitis of the foot
- commonly in the anterior/posterior tibialis, fibulas muscle tendons, or Achilles tendon
- exacerbated with stretch, resistance, and palpation
- Achilles tendon symptoms usually 2-6 cm above the insertion site
Anterior versus posterior shin splints
- Anterior: overuse & weakness of the ant. tibialis, decreased ROM of gastroc-soleus complex
- Posterior: posterior tibialis weakness/inflammation, tight gastroc-soleus complex, increased foot pronation
Protection phase for non-operative heel/foot pain
- treat local inflammation (POLICE)
- cross friction massage
- submax muscle setting contractions
- passive stretch to plantar flexors
- AROM within pain free range
- activity modification or avoidance
- supportive taping or orthotic prescription
Controlled motion phase for non-operative heel/foot pain
- assess entire kinematic chain once scute symptoms are alleviated
- pain with initial WBing/first few steps
- educate on gentle warm uo before aggressive exercise, recovery time, and footwear
- stretch plantar fascia with great toe extension & eversion
- progress resistive exercises as tolerated in both open/closed chain positions
- intrinsic foot muscle strengthening is beneficial for pt’s with plantar fascia
Achilles tendon rupture risk factors
- 4th/5th decade of life
- males more likely than females
- jumping or landing task
- degenerative & mechanical factors increase risk
- use of quinolone antibiotics & pre injury steroid injections in the tendon increase risk
- typically surgery for younger persons looking to return to sport
- conservative care for older or more sedentary individuals
Post operative management for an Achilles tendon repair
- no more than 2 weeks of protected WBing
- use of protective device for 2-4 weeks post-op
- avoid early end range AROM DF
- outcome measures: foot & ankle ability measure (FAAM) and achilles tendon total rupture score (ATRS)
Weight bearing guidelines post-op Achilles tendon repair
- WBAT w/crutches immediately after surgery or after 1-2 wks in a CAM boot
- progress gradually to full WBing status between weeks 3-6 post-op
- orthosis is worn during all WBing activities for 6-8 wks after surgery
- FBW w/o orthosis using shoes w/bilateral heel lifts can begin around 6-8 wks post-op (remove 1 heel lift every 1-2 wks)
ROM guidelines post-op Achilles tendon repair
- AROM immediately or within first 1-2 wks post-op (avoid 15-20 degrees of DF)
- Wks 4-6: with orthosis removed begin INV/EV with ankle in PF
- Wks 6-8: progress to DF beyond neutral up to 10 degrees with orthosis & progress INV/EV
Criteria to discontinue CAM boot
- 0 degrees DF AROM
- pain free ambulation (non-antalgic)
- full discontinue of boot & shoe lifts by wk 8
Max protection phase post-op to 2 wks for Achilles tendon repair
- Precautions: maintain post-op splint or cast per surgeon
- joint mobilizations
- initiate PROM if patient is in removable splint
- PF as tolerated
- DF to minimal stretch (DO NOT stretch aggressively)
- initiate foot intrinsic exercises
- toe taps, arch doming, toe spreading, towel crunches
- ankle AROM/alphabets
- SLR 4-way
- all exercises should be pain free
Transition to moderate protection phase post-op Achilles tendon repair
- wks 2-6
- initiate pain free AROM PF, INV, EV, and continue PROM
- initiate weight shifts out of boot wk 4 as tolerated
- seated heal raises
- BAPS board seated as tolerated
- recumbent bike with CAM boot
- glute & lumbopelvic strength & stability
Exercises to initiate at 4 wks post-op Achilles tendon repair
- progressive resisted PF, INV, and EV with TheraBand
- seated heel raises with lightweight
- balance/proprioceptive training on stable surface once able to WB in neutral ankle position out of boot
- standing BAPS board as tolerated (PWB or FWB)
- light weight double leg press
Strength phase post-op Achilles tendon repair
- wks 6-12
- full PROM/AROM PF, INV, and EV
- joint mobilizations
- balance training on unstable surface
- closed chain hip & knee strengthening
- recumbent bike in shoe
- Wk 8: standing heel raise progression as able & double leg starting in neutral ankle DF
- Wk 10: step holds with focus on LE alignment & balance & heel taps
Minimum protection phase post-op Achilles tendon repair
- begins about wks 12-16
- heel lowering exercises in unilateral stance
- descending stairs step over step
- plyometric training started in pool
- functional criteria dictates return on over ground plyometrics & running programs
Functional phase post-op Achilles tendon repair
- emphasize strengthening at end range plantarflexion
- heels raises in knee flexion
- continued progression of strength/stability/balance exercise on stable/unstable surfaces to correct altered mechanics
- initiate plyometric progression
- step/hop holds for training on LE landing mechanics for jogging
- resisted jogging in place with resistance in all planes
- sports specific exercise/agility progression
Criteria to initiate return to running/jumping post-op Achilles tendon repair
- btw wks 12-16
- 95% symmetry ROM
- 95% symmetry calf circumference
- normalized gait & jogging mechanics
- 25 single leg heel raises with heel height within 25% of uninvolved limb
Criteria for return to sport post-op Achilles tendon repair
- b/w 6-9 months
- physician clearance
- 95% symmetry ROM
- normalized gait & jogging mechanics
- < or equal to 10% PF strength difference in 0 degrees DF and < or equal to 25% PF strength difference in 20 degrees PF
- 90% symmetry on Y-balance test
- 90% symmetry on SL hop testing
Intrinsic versus extrinsic factors for ankle sprain
- Intrinsic: previous sprain & decreased DF ROM
- Extrinsic: athletic participation without bracing, poor warmup, poor participation in balance.proprioceptive training
Max protection phase for Anke sprain
- Estim and US have no benefit
- ice to control swelling for first 24-48 hrs
- provide brace, walking boot, semi-rigid orthotic to facilitate progressive WBing
- joint mobs
- sagittal plane AROM
- muscle setting and toe curls for muscle integrity & circulation
Controlled motion phase for ankle sprain
- continued bracing/support
- normalize gait
- cross friction massage
- joint mobs
- progress resistance training but avoid end range
- stretch gastroc-soleus complex
- progress to single limb balance training
Return to function phase for ankle sprain
- TheraBand resistance ankle exercises in open chain
- neuromuscular reduction training in full weight bearing
- dynamic gait patterns
- balance training on unstable surfaces
- plyometrics
Plantar Fasciitis
- inflammation of the plantar fascia
- pain on bottom of foot usually towards heel
- overuse injury
Intrinsic versus extrinsic factors for plantar Fasciitis
- Intrinsic: obesity, reduced strength in PF, reduced ROM in DF, & foot/LE structural abnormalities
- Extrinsic: new excessive amounts of exercise, improper footwear, & training on surfaces with no cushion
Symptoms of plantar Fasciitis
- plantar medial heel pain
- sharp or aching pain in arch at rest or during WBing
- excessive pronation
- delayed supination
- limited DF
- pain with first steps in morning/after rest
Special tests for Plantar Fasciitis
- Windlass test (patient seated with knee bent to 90 degrees, lift great toe MTP while allowing IP to flex; pos. = pain & limited ROM)
- palpation of the plantar medial tubercle = pain
Interventions for Plantar Fasciitis
- STM during acute phase
- Stretch gastroc-soleus complex & plantar fascia
- strengthen intrinsic foot muscles, posterior leg, & neuro reeducation
- educate patient on footwear & orthotics
- antipronation taping PRN
Acute phase for Planatr Fasciitis
- 1-2 wks
- stretch gastroc, soleus, & plantar fascia
- STM on gastroc-soleus complex
- antipronation taping
- education on medial longitudinal arch & cushion the heel orthotics & footwear
- ice: rolling foot over frozen water bottle
Subacute phase for Plantar Fasciitis
- wks 3-5
- stretch gastroc, soleus, & plantar fascia
- strengthen intrinsic muscles, the ankle in all ROMs, & the gastroc-soleus complex
- ice: roll foot over a frozen water bottle
Subacute phase for Plantar Fasciitis
- wks 3-5
- stretch gastroc, soleus, & plantar fascia
- strengthen intrinsic muscles, the ankle in all ROMs, & the gastroc-soleus complex
- ice: roll foot over a frozen water bottle
Return to function for Planatr Fasciitis
- wks 6+
- stretch gastroc, soleus, & plantar fascia
- strengthen calf muscles, intrinsics, & all ankle ROMs
- plyometrics
- ice: roll foot over frozen water bottle
